Chapter 36: Introduction to the Nervous System
To evaluate a client's cerebellar function, a nurse should ask:
"Do you have any problem with balance?"
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?
"Who is the president of the United States?"
The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of:
15
Which of the following Glasgow Coma Scale scores indicates coma?
7
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?
Assess the client for medication allergies.
A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the:
Between the first and second lumbar vertebrae
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?
CN I
A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem?
Cerebellar dysfunction
An 80-year-old man has been brought to the emergency department (ED) by his daughter, who states that her father has become confused and agitated over the past several days. The daughter expresses fear that her father is "getting senile" and states that this concern is what prompted her to seek care. The ED nurse and the other members of the care team should prioritize which of the following aspects of assessment?
Differentiating delirium from dementia
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?
Encourage the client to drink liberal amounts of fluids
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?
Ensure that no client care equipment containing metal enters the room where the MRI is located.
A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?
Hearing and equilibrium
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?
Hot or cold packs
What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface?
Pia mater
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?
Reduction in cerebral blood flow
A nurse who works in a neurological rehabilitation facility is aware of the complex structure and function of the nervous system. Which of the following statements most accurately describes an aspect of the structure of the neurological system?
The sympathetic nervous system is a component of the peripheral nervous system (PNS).
A client had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the client and family that evening. What does this phone call enable the nurse to determine?
Whether the client has had any complications of the test
Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question?
abducens, oculomotor, trochlear
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?
ataxia
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:
cranial nerves IX and X
Which cerebral lobes is the largest and controls abstract thought?
frontal
Which lobe of the brain is responsible for concentration and abstract thought?
frontal
A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:
Cerebellum.
The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis?
"Client demonstrates an absence of deep tendon reflexes."
A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?
"Remain prone for 2 to 3 hours."
A 78-year-old resident of a long-term care facility has left the majority of his supper tray untouched, and the nurse has asked him about the reason for this. The resident states, "For a long time now, food just doesn't taste as well as it used to." The nurse should be aware that the etiology of this problem is most likely to involve:
Age-related changes to the neurological system
The nurse caring for an 80-year-old client knows that the client has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation?
Age-related neurologic changes
A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?
Brain stem
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?
Dysfunction of the vagus nerve
A client has been in a coma since being in a motor vehicle accident. Emergency surgery relieved intracranial pressure but, to date, the client has not regained consciousness. Which motor response is indicative of the most serious condition?
decerebrate
The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing?
medulla oblongata
An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?
smoker detector
A client has been exhibiting neurological symptoms for several weeks and the neurologist is admitting the client to the hospital for extensive testing. Since diagnostics have not yet revealed the cause of the symptoms, which client statement would indicate the need for further client education?
It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!"
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to
refrain from eating or drinking for now.
A client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which important post-procedure nursing interventions should be performed to ensure maximum comfort for the client? Select all that apply.
• Encourage a liberal fluid intake for the client. • Position the client flat for at least three hours or as directed by the physician • inspect the injection site for swelling or hematoma
The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client?
Transcranial Doppler
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in
thought content.
The nurse is completing the physical assessment of a client suspected of a neurological disorder. The client reports having recently suffered a head trauma. In such a case, the nurse should:
not move or manipulate the client's head while assessing for bleeding or swelling.
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?
occipital
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?
occipital
A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test?
"You will need to lie still throughout the procedure."
Cranial nerve IX is also known as which of the following?
Glossopharyngeal
The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures?
Guide the client through the performance of rapid, alternating movements.
